I'm a clinical psychologist and psychoanalyst. For 20+ years I've been practicing on 12th Street, around the corner from the Forbes Building and right in the middle of the digital revolution — both of them. Having written for professional audiences and become a not infrequent source (e.g., Wired, New York, NY Times, The Today Show) I figured Web 2.0 was the right time to put my ideas out there myself. First at True/Slant, then Psychology Today, and now at Forbes, my "beat" includes clinical insights and research developments useful for building an authentically good life in our increasingly complex and technologically-mediated world, along with identifying those choices that promise more than they can deliver. Along with my full-time private practice I'm a Training and Supervising Psychoanalyst at the William Alanson White Institute and a Clinical Assistant Professor in Psychiatry at New York Medical College.

Mary Richardson Kennedy, estranged wife of Robert F. Kennedy, Jr., took her own life, leaving behind the sour scent of senseless loss. You and I, as well as her well-heeled Bedford neighbors inconvenienced by helicopters, reporters, and notoriety, are once again reminded of the lesson tragedies like this teach: depression kills. And as I learned from a recent case of mine, it is a lesson the bean counters at United Behavioral Health desperately need to learn but probably won’t.

I’ve got no direct knowledge about this suicide. Just media reports. Nevertheless, I think it safe to say that she probably had resources enough to access the best care possible. Still she died, showing that depression can become a more powerful foe than the most potent combination of support, drugs, and therapy. As successful as treatments can be for some, they still fail for others. Some people fall through the cracks into suicidal hopelessness, as Ms. Kennedy apparently did, because available treatments have not yet fully domesticated depression.

Unfortunately, and what is in my opinion a shameful example of corporate irresponsibility, United Behavioral Health (UBH), a company that manages mental health care, acts as though depression is a riddle solved. They have developed guidelines and procedures that deny care to the very people who most need help, those for whom biology and biography conspire to kill hope.

– UBH does not mention treatment-resistant depression even once while the APA includes 61 mentions.

– The APA recommends with “susbstantial clinical confidence” that “it is important to collaborate with the patient in decision making and attend to the patient’s preferences and concerns about treatment” while UBH only includes a mention of patient preference for adults with “mild” depression and when the question is whether or not to combine drugs and talk therapy.

UBH has put in place a strategy that makes perfect business sense—less care, more profit—while being clinically dangerous. And I’m pretty sure they do not tell the employers who purchase their services, “Oh, by the way, we hope you don’t mind but we’re going to exploit your most vulnerable employees, risking their lives to keep our costs down.”

Why am I picking on UBH? Well, they’re the “care-rationing” company with whom I’ve recently had dealings. I’m sure there are lots of other companies out there who similarly make money by denying mental health-care insurance benefits to those who deserve and need them. I just happen to have direct knowledge about how UBH works and what they do. And my recent experience with UBH can only be described as a corporate shakedown. They held their guidelines to my head and said “give us your fees or risk having your patient die.”

Here’s a thumbnail of their irresponsibility. They “reviewed” my care of a chronically-depressed, intermittently suicidal man I’ve treated for a dozen years. Both before I met him and during the course of our work he has tried every available, reasonable treatment option. Nevertheless, waves of hopelessness would crash over him—sometimes for hours, sometimes for days, sometimes for weeks. When the noonday demon struck, he knew he could reach out to me and sometimes find some relief. We tried everything and he did made significant progress in his life, both personally and in his career, despite the sword hanging over his head.

When I answered the first call to “review the treatment” I said the goal of treatment was keeping him alive, or in the language of the UBH care guidelines “to protect susceptible patients from relapse.” The conclusion to that review was being told I was doing excellent work with this man and that I should contact them should a “higher-level of service” be required.

Pretty good! So why am I complaining?

Well, three weeks later I got another call from a UBH “care-rationer” who wanted to review the review. Rationer #2’s conclusion after 12 minutes of conversation was to deny further treatment. The logic of her review was predicated on the assumption that all depression is treatable because their guidelines say so. Therefore, if he still had problems, that meant the treatment was ineffective. So much for protecting from relapse! The first “care-rationer” needed to check to make sure that he was sick enough to warrant ongoing treatment while the second was there to show that because he was sick enough to warrant ongoing treatment that meant that the care he was receiving wasn’t working and had to be terminated. Kind of like saying that if insulin helps someone manage diabetes but doesn’t cure it then it shouldn’t be covered.

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Thank you to all the docs who let this happen, circa 1990 or so, dunno. Physicians of all specialties, but perhaps psychiatrists more so than others, have lost control of their profession. Obviously so have psychologists. Psychoanalysts never even put up a fight.

I got two words for you: CASH. ONLY.

And if that doesn’t work, there are no more outs, except to change careers.

I feel for you. This is a common problem in every industry in business-not just yours. Companies are hiring “monkeys” to just hack out the work instead of experienced professionals that really know what they are doing in order to save money, contribute to nepotistic hiring practices to make someone “happy”, etc. THIS is the MAJOR problem with our country-incompetents are running it from the top down. I am frustrated as well, as I am contacted time and time again by I.T. recruiters that have accents as thick as the concrete that paves our roads so you can’t understand them, don’t know the business they are recruiting for, etc. What happens is seasoned professionals like us don’t have a chance when it comes to doing the job right because we can’t make the ignorant/incompetent understand what right is. PERIOD. I suggest you write a letter to the head of the insurance company AND to the American Psychiatric Association and shake some trees. You might just get some apples off those trees once it starts rocking. AND I would hold the insurance company responsible if I were your patient’s family and, God forbid, anything happens to him/her because they are cutting the treatment allowance short for no good reason, other than the “care-rationer” (the name says it all) doesn’t know what the heck they are doing. Good luck!

They call themselves “care managers” not “care rationers” but I like the later. And thanks for the luck (although don’t agree that there’s a correlation between competence and accent — some of the best, smartest people I know speak with an accent!)

This is the case with most insurance companies and has been for decades. Ill be the next stat Im sure as Ive been trying to get treatment for anxiety and depression since I was a pre-teen. No one takes it seriously ; everyone wants you to snap out of it. Its even worse with Medicare – One would assume if you’ve gotten disability for mental illness then they should want you to get support so you can get better and off disability. The good thing is that they passed a mental health parity law but its still 60/40 to 80/20…The other good thing is unlike private insurers, Medicare doesnt limit the # of visits you can have. THE REALLY BAD THING IS THAT ITS ALMOST IMPOSSIBLE TO FIND QUALIFIED AND GOOD REPUTABLE PSYCHIATRISTS AND PSYCHOLOGISTS THAT TAKE MEDICARE, AND EVEN WORSE OUTPATIENT PROGRAMS OR RESIDENTIAL PROGRAMS THAT COST $2000 OR MORE A DAY – more than my monthly income. So people like me are stuck in a never ending circle and have no chance for improvement unless they try to commit suicide and even then its usually too late

Anyone unfortunate enough to have to deal with mental health issues, either as a patient or someone trying to live with the patient, is in for bad news all the way around. The insurance companies seem to be much more comfortable dealing with addictions than other mental health issues.

What gave these bozos the idea that such things as depression are cureable. God knows what their response to Schizophrenia and Bi-polar. On average it takes 10 years to diagnose and develop an effective treatment for someone. What added insult to injury was the decision in the Reagan administration to only house the most dangerous and most incapacitated in institutions and move the rest into society. There were supposed to be provisions like group homes and other support services, but alas, nobody wanted to spend the money for those support services, particularly the cheaper states, Texas. So we have a lot of nut cases running around often untreated and not provided for in any way, the homeless.

Many refer to these homeless, left out in the elements as lazy bums who need to get sober and get a job. Most people would not be comfortable working with someone who is bi-polar or a schizo. The woman you’re working with to peel potatoes and fry them up in a deep fryer keeps looking at you for some reason. She’s not on her bi-polar medication and she’s all worked up and pumped up and has a streak of paranoia working today and she thinks you’ve been talking about her and she’s trying to decide whether to cut or stab you with the knife or grab you hand and stick it in the fryer grease. Even worse, she’s arguing with someone not there and keeps throwing pans as she gets madder and now she’s headed for the knives.

The worst part of this is people who have been identified as potentially dangerous and known to not follow their regime for when they are out of sorts are not dealt with until someone is seriously injured or killed and then it’s time to hang the guilty dog. At this point there is no mental illness, only retribution so the DA can add another to his win column. The law absolutely leaves many schizos vulnerable and most bi-polar people. I’ve had conversations with a number of bi-polar individuals and most, not all, have told me they have an understanding of what they are doing or starting to do, the results and consequences, but they are so angry, they discard the consequences and are compelled to complete the action. Based on current law, the fact they can say they were knowledgeable of the expected results of their actions and the consequences, they are are guilty, guilty, guilty. Memory of what occurred afterwards is sometimes sketchy.

The Texas approach is to let them fend for themselves and when they commit a crime, ignore the mental issues and jail them.

Just want to point out that people suffering from a serious mental illness are far more likely to be the victims of random violence and crime than the perpetrators. We need parity not just for health-care but for compassion as well. People should not be uncomfortable working with someone with a mental illness, not at all.

I agree, my point was to those folks who think these folks ought to be getting jobs , but are cutting the services that would make that possible. Having a lifetime relationship with someone who goes fairly quickly from tolerable and generally able to function (although there were some things that seemed a little odd, there was no indication of a serious illness) to crazy as hell that progressed into scary crazy as hell with a building collection of guns and knives with personality changes sometimes occuring mid-sentence. The best anyone has been able to advise me is there was a bi-polar person hiding, mostly controlled, but not always, inside the person I knew. Doctors suspect some hormone changes brought the new bi-polar person out.

It took a full ten years plus to figure out what was wrong and work out a treatment that helped maintain life in a liveable condition. It was five years to even get to the point of seeing a doctor. This person had a fear of being told they were troubled and every attempt to visit a doctor that might help resulted in a walk-out. Nothing like trying to convince a crazy paranoid person they really are crazy.

I won’t continue further but pay attention to what I say about Texas. If you are mentally ill and commit a crime in Texas, you will go to jail. Ther is no longer an effective system for treating the mentally ill in Texas. If you are mentally ill and without support, you may get some treatment if you go on your own volition or someone sees to it that you go, oterwise, nothing. If you happen to have some income, but no insurance, your chances of getting help are non-existant.

I realize you are a mental health professional, but this is one time I have to give the State’s people good marks. After getting a diagnosis, this person saw three different Psychiatrist and underwent 2 self-admitted hospital stays with no progress over the next five years. After a serious income reducing shock, the person qualified to go to a State outpatient facility where the nurse-practioner started the person on medication that after some adjustments has allowed them to live a mostly normal life. I’m no doctor, but after almost twenty years, I can identify someone who is bi-polar about as well as a doctor. I didn’t like any of the care or treatment received in the facility. The insurance company paid off like a slot machine for a course of addiction treatment. It appears most everyone regardless of problem was run through the addiction treatment process so it was easy to file on the insurance company. there was some treatment for the real problem, but everybody got the addiction treatment.